De-novo headache with transient vertebro-basilar symptoms: role of embryonic hypoglossal artery

Abstract

We report the case of a 56-year-old man with acute onset of de-novo stabbing, pulsating and diffuse headache with subsequent appearance (within few minutes) of posterior fossa symptoms (vomiting, postural instability, anisocoria, incoordination, dysarthria, retropulsion) lasting 9-12 h. Recurrent hypertensive crises were detected during the acute observation in the Emergency Room, even in the absence of previous history of hypertension. Once subarachnoid hemorrhage and focal lesions (vascular and non-vascular) were excluded, brain computerized tomography-angiography and digital subtraction angiography disclosed the presence of left persistent primitive hypoglossal artery with bilateral vertebral artery hypoplasia and a slight aneurysmal dilation of the anterior communicating artery. Brain magnetic resonance study performed 24 h after onset of symptoms was negative for recent ischemic lesions. The clinical features of this rare vascular condition are discussed as a possible cause of magnetic resonance (diffusion weighted imaging) negative vertebro-basilar transient ischemic attack.

Fig. 1

a Axial brain CT-angiography, b, c MIP and 3D-reconstruction CT-angiography showing left PPHA (arrows). d Three-dimensional-VR CT-angiography showing PPHA (arrow) entering the posterior cranial fossa through an enlarged hypoglossal canal and thus joining the lower portion of the basilar artery, and in e PPHA (arrow) as a large vessel originating from the internal carotid artery at the C2 vertebra level